NCC241302_FRO Submitted_20240429

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name: Rocky Mount - Vepco Battleboro 115kV Rebuild
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project #
No
2. Location of land -disturbing activity: County: Nash City or Township: Rocky Mount
Highway/Street: 550 Old Mill Road Latitude: 35.952000 Longitude:-77.833000
3. Approximate date land -disturbing activity will commence: 6/3/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Commercial -
Linear Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 101.60
6. The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? No
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Nuwan Wijesuriya E-mail Address: [e-mail]
Phone:[phone] Mobile:[phone]
9. Landowner(s) of Record:
Landowners of Record

Part B
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is an individual(s), the
name(s) of the owner(s) may be listed as the financially responsible party(ies).
Pri ary Financially Res onsible Part
Company Name
Email
Business Phone
Mobile Phone
Duke Energy Progress, LLC
Nuwan.Wijesuriya@Duke-
Energy.com
919.931.6655
Physical Address
Mailing Address
Street 1
City
State
Zip
Street 1
City
State
Zip
410 South
Wilmington Street
Raleigh
NC
27601
410 South
Wilmin ton Street
Raleigh
NC
27601
Additional Financially Responsible Parties
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the
landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control
plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Information
Name
Email
Business Phone
Mobile Phone
Duke Energy Progress, LLC
nuwan.wijesuriya@duke-
energy. om
1-(919)-546-2090
1-(919)-931-6655
Ph sical Address
Mailing Address
Street 1
City
State
Zip
Street 1
City
State
Zip
410 S. Wilmington
St
Raleigh
North
Carolina
27601
410 S. Wilmington
St
Raleigh
North
Carolina
27601
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent who is registered on the NC Secretary of State business registry:
North Carolina Agent Information
Name
Email
Business Phone
Mobile Phone
Ph sical Address
Mailing Address
Street 1
city
State
Zip
Street 1
city
State
Zip
Engineering/Consulting Firm Information
Name
I Email
Business Phone
Mobile Phone
Dewberry
Engineers Inc
I [e-mail]
8047674712
Physical Address
Mailing Address
Street 1
City
State
Zip
Street 1
City
State
Zi
4805 Lake Brook
Dr
Glen Allen
VA
23060
4805 Lake Brook
Dr
Glen Allen
VA
23060

Additional Details
Stream Classification: NSW: Nutrient Sensitive Waters; WS-IV: Water Supply IV
Was Express Review Requested: Yes
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N. Salisbury Street, 6,,Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699 1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report,plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article, , . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
✓❑ I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
n The information submitted in this NOI is,to the best of my knowledge and belief,true,accurate,and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
✓0 I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name(must match Ala): Rocky Mount - Vepco Battleboro 115 kV Rebuild
Specific Lot Numbers(must match Alb):
Permittee(must match 81): Duke Energy Progress, LLC
Legally Responsible Person (must match B2&83): Nuwan Wijesuriya
Title of Legally Responsible Person (must match B3b): Lead Transmission Permitting Manager
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 919.931.6655
4/19/24
—
Signature of Legal espo a Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president,or a manager that is authorized in accordance with Part lV, Section B,
Item(6)of the NCG010000 permit.